AHCCCS Fee-For-Service Program T(RBHA) Drug List (BHDL ... · 2 Optum Rx Prior Authorization...

AHCCCS Fee-For-Service Program

T(RBHA) Drug List (BHDL)

INTRODUCTION

AHCCCS is pleased to provide the AHCCCS FFS Program T(RBHA)Drug List (BHDL) to be used when

prescribing behavioral health medications for AHCCCS FFS members. For clarification, this BHDL is only

for the AHCCCS FFS members and it does not apply to AHCCCS members enrolled in any of the AHCCCS

Managed Care Contractors’ Health Plans. This document provides general information regarding the

AHCCCS pharmacy benefit for FFS members. The drugs listed on the BHDL are intended to provide

clinically appropriate, cost-effective options for AHCCCS FFS members who require medically necessary

behavioral health treatment. The drugs listed on the BHDL have been reviewed and approved by the

Pharmacy and Therapeutics (P&T) Committee. However, the BHDL is not intended as a comprehensive

listing of all drugs that may be reimbursed by AHCCCS. If a drug is not listed on the BHDL and is

determined to be medically necessary, it may be requested through the prior authorization process.

OptumRx is the Pharmacy Benefit Manager (PBM) for the AHCCCS FFS Program.

OptumRx will facilitate the administration of the pharmacy benefit for the following populations:

Acute FFS – Title XIX

Long Term Care FFS – Title XIX

KidsCare FFS – Title XXI

AHCCCS FFS Members who are enrolled in a TRBHA (Tribal/Regional Behavioral

Health Authority)

Members who are Dual Eligibles (AHCCCS FFS members who are also eligible for

Medicare)

Federal Emergency Services (FES) Members whose coverage is limited to emergency

dialysis service

Members may obtain additional pharmacy information on the OptumRx website at:

https://ahcccs.rxportal.mycatamaranrx.com/rxclaim/portal/memberLogin

Members and prescribing clinicians may also contact the OptumRx Customer Service Center at 1

(855) 577-6310, 24 hours per day, 365 days per year.

For Prior Authorization Requests and Information:

Prescribing Clinicians may fax the completed prior authorization form to the OptumRx Prior

Authorization Unit at 1 (866) 463-4830.

For telephonic requests for information, prescribing clinicians may call 1 (855) 577-6310 for

assistance.

Prescribers preferring to send a written request via the US Mail, may send the request to the

following address:

Optum Rx Prior Authorization Department

P.O. Box 5252

Lisle, IL 60532- 5252

With regard to federal legend drugs, medically necessary federally reimbursable outpatient prescription drugs

are covered for eligible AHCCCS FFS members when prescribed by an AHCCCS registered clinician who is

licensed to prescribe federal legend drugs in the State of Arizona. Some medications may require prior

authorization approval prior to dispensing the medication to the member.

Pharmacy and Therapeutics (P&T) Committee

The P&T Committee, comprised of physicians and pharmacists, meets quarterly to discuss a variety of clinical

issues, which pertain to drug selections, including formulary additions, deletions and changes as well as

pharmacy program management.

The P&T Committee evaluates clinical information for newly marketed drugs within 180 days of market

launch and current medications on an annual basis. The evaluation may include, but is not limited to the

following review categories:

Safety

Efficacy

Comparative data and studies

FDA approved indications

Treatment and consensus guidelines

Adverse events

Contraindications/Warnings/Precautions

Pharmacokinetics

Dosage frequency and formulations

Patient administration/compliance considerations

Medical outcome and pharmacoeconomic studies

When a new drug is considered for inclusion on the ADL, it will be reviewed relative to similar drugs

currently included on the ADL. The review process of a therapeutic class continually promotes the most

clinically appropriate, useful, and cost-effective agents. All of the information in the ADL is provided as a

reference for drug therapy selection. Specific drug selection for an individual member rests solely with the

prescribing clinician.

Generic Drugs

Generic substitution is a pharmacy action whereby a generic equivalent of a drug is dispensed rather than the

brand name drug product. The AHCCCS pharmacy benefit requires mandatory generic substitution. This

means that if a generic drug is equivalent to the brand reference drug and is available, the generic drug will be required for the filling and dispensing of the prescription for payment through the point-of-sale claims adjudication system. Generically available drugs are indicated on the ADL and are printed in lower case, for

example, amoxacillin.

The ADL is organized by sections. Each section includes therapeutic groups identified by either a drug class

or disease state. Products are listed with the generic name and the brand name is included as a reference to

assist the prescribing clinicians in product recognition. Generics drugs are to be considered as the first line of

prescribing. AHCCCS and its Contractors are required to use the most cost effective (least costly) clinically

appropriate pharmaceutical treatment. The ADL also covers selected over-the-counter (OTC) products.

Prescribing clinicians are encouraged to prescribe OTC medications when clinically appropriate.

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Prior Authorization Procedures For Drugs Not Listed On The ADL

The drugs on the ADL have been selected to provide the most clinically appropriate and cost-effective

medications for AHCCCS FFS members. When a drug not listed on the ADL is determined to be medically

necessary for the appropriate medical management of a specific member, the prescriber must submit a prior

authorization request specifying the reasons supporting the medical necessity of the particular drug for the

AHCCCS member. Requests for these exceptions must be submitted in writing by the prescribing clinician

on the OptumRx-AHCCCS Prior Authorization Form and faxed to:

OptumRx - Prior Authorization Department

Fax Number: 1 (866) 463-4830

Telephone Number: 1 (855) 577-6310

The OptumRx-AHCCCS Prior Authorization Request Form is available on the AHCCCS website at

www.azahcccs.gov under the Pharmacy Information section on the right side of the website. Appropriate

clinical documentation must be provided to support the medical necessity for the drug being requested.

Responses to requests will be provided within 2 business days of receipt unless the request is identified as

urgent. If a request is identified as urgent, a response will be provided within 1 business day.

Prescribing clinicians are requested to adhere to the ADL when prescribing for AHCCCS FFS members. If a

pharmacist receives a prescription for a drug not listed on the ADL, the pharmacist is expected to contact the

prescribing clinician and request that the prescription be changed to a medication included on the ADL. If a

medication on the ADL is not appropriate, the prescribing clinician is to be instructed to submit a prior

authorization request form to OptumRx. Please contact the OptumRx Prior Authorization Department at 1

(855) 577-6310 with questions concerning the prior authorization process.

Dose Optimization Program – Quantity Limits (QL)

The ADL utilizes Quantity Limits for several drugs listed on the ADL. The intent of the quantity limits is to

promote dose optimization and efficient medication dosing. Prescriptions for monthly quantities greater than

the indicated limit require a prior authorization approval. For quantities greater than those listed on the ADL,

the prescribing clinician must submit a prior authorization request with supporting documentation for the increased quantity of medication. The Dose Optimization Program is designed to consolidate medication

dosage to the most efficient daily quantity to increase member adherence to therapy and also promote the

efficient use of health care dollars. The limits for the program are established based on FDA approval for

dosing and the availability of the total daily dose in the least amount of tablets or capsules daily.

Quantity limits are loaded in the prescription claims processing system to promote minimized dosing. The

pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the

prescribing clinician for more efficient dosing.

Additions to the Dose Optimization Program are made from time to time and providers notified accordingly.

As always, we recognize that a number of member-specific variables must be taken into consideration when

drug therapy is prescribed and therefore overrides will be available through the prior authorization process.

For any questions, please contact the OptumRx Customer Service Center at 1 (855) 577-6310.

Prescription Utilization Parameters

AHCCCS members may reorder or refill a non-narcotic prescription when seventy-five percent (75%) of the

medication has been used. Members may reorder or refill a narcotic prescription when eighty-five percent

(85%) of the medication has been used. If a point-of-sale claim is submitted before 75% of the non-narcotic medication has been used, based on the

original days supply submitted on the claim, the claim will reject with a "refill too soon" message. The same

will happen with for narcotic prescription refills not meeting the 85% utilization. Please call the OptumRx

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http://www.azahcccs.gov/

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Customer Service Department at 1 (855) 577-6310 with questions or for help with dosage change

authorization override.

Drug Efficacy Study Implementation (DESI) Drugs

Drugs that were initially marketed between the years of 1938 and 1962 were approved as safe but were not required to

provide the effectiveness for FDA approval. Beginning in 1962 legislation required all new drugs to be both safe and

effective before they could be approved to be available and marketed. This requirement also applied retroactively to all

drugs approved as safe from the years 1938-1962. As a result, the FDA established the DESI program to review the

labeled indications and the effectiveness of the pre-1962 drugs

and to provide a determination of effectiveness. The “fully effective” determination was given for most of these products and they remain in the marketplace today. A few DESI products remain classified as “less than fully

effective” and are awaiting final administrative disposition from the FDA. In addition, if a drug is classified as DESI,

there are many products listed as identical, similar, or related to actual DESI products. The AHCCCS FFS ADL does not

pay for claims for DESI drugs that are considered “less than fully effective” drug products.

AHCCCS FFS Plan Exclusions

The following are excluded from coverage under the outpatient pharmacy benefit:

DESI Drugs that are determined to be “less than fully effective”

Experimental / research drugs

Cosmetic drugs

Cosmetic drugs for hair growth

Child and Adolescent Immunizations

Nutritional / diet supplements

Blood and blood plasma products

Drugs and products to promote fertility

Drugs used for erectile dysfunction

Drugs from manufacturers that do not participate in the FFS Medicaid Drug Rebate Program

Diagnostic products

Medical supplies except:

o Syringes

o Needles

o Lancets

o Alcohol Swabs o Blood glucose meters and test strips o Inhale Spacers

Intrauterine Devices

Notice

AHCCCS and OptumRx provide the information contained in the ADL, solely for the convenience of prescribing

clinicians. AHCCCS does not warrant or assure accuracy of such information nor is the ADL intended to be an all

inclusive medication list. This ADL is not intended to be a substitute for the knowledge, expertise, skill and

judgment of the medical provider in their choice of prescription drugs.

AHCCCS assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in

whole or in part, on the information contained herein. The medical provider must consult the drug manufacturer’s

product literature or standard references for more detailed information.

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Drug Class/Drug Name Reference Brand Name Brand Only

Preferred Drug

Status PRIOR AUTHORIZATION REQUIRED Quantity Limit QL Days ADHD

AMPHETAMINES

AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR ADDERALL XR Brand Only Preferred Drug PA Required for ages < 6 years 30.00 30.00

AMPHETAMINE-DEXTROAMPHETAMINE TABLETS ADDERALL

Brand and

Generic Preferred Drug PA Required for ages < 6 years 60.00 30.00

DEXTROAMPHETAMINE SULFATE CAPSULE 24-HOUR DEXEDRINE Preferred Drug PA Required for ages < 6 years 60.00 30.00

DEXTROAMPHETAMINE SULFATE TABLETS ZENZEDI Preferred Drug PA Required for ages < 6 years 60.00 30.00

LISDEXAMFETAMINE DIMESYLATE CAPSULES VYVANSE Brand Only Preferred Drug PA Required for ages < 6 years 30.00 30.00

STIMULANTS

DEXMETHYLPHENIDATE HCL CAPSULE 24-HOUR FOCALIN XR Brand Only Preferred Drug PA Required for ages < 6 years 60.00 30.00

DEXMETHYLPHENIDATE HCL TABLETS FOCALIN Brand Only Preferred Drug PA Required for ages < 6 years 60.00 30.00

METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN Brand Only Preferred Drug PA Required for ages < 6 years 90.00 30.00

METHYLPHENIDATE HCL CHEWABLE TABLETS EXTENDED RELEASE QUILLICHEW ER Brand Only Preferred Drug PA Required for ages < 6 years 30.00 30.00

METHYLPHENIDATE HCL CAPSULE 24-HOUR RITALIN LA /APTENSIO XR Brand Only Preferred Drug PA Required for ages < 6 years 30.00 30.00

METHYLPHENIDATE HCL CAPSULE 24-HOUR VARIOUS Preferred Drug PA Required for ages < 6 years 30.00 30.00

METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE METADATE CD Preferred Drug PA Required for ages < 6 years 30.00 30.00

METHYLPHENIDATE PATCH DAYTRANA Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00

METHYLPHENIDATE HCL SOLUTION METHYLIN Brand Only Preferred Drug PA Required for ages < 6 years 300.00 30.00

METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR Brand Only Preferred Drug PA Required for ages < 6 years 150.00 30.00

METHYLPHENIDATE HCL TABLETS VARIOUS Preferred Drug PA Required for ages < 6 years 90.00 30.00

METHYLPHENIDATE HCL TABLET 24-HOUR METHYLPHENIDATE HCL ER Preferred Drug PA Required for ages < 6 years 60.00 30.00

METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE METHYLPHENIDATE HCL ER Preferred Drug PA Required for ages < 6 years 60.00 30.00

MISCELLANEOUS AGENTS

ATOMOXETINE HCL CAPSULES STRATTERA Brand Only Preferred Drug PA Required for ages < 6 years 30.00 30.00

CENTRAL ALPHA AGONISTS

CLONIDINE HCL Catapres PA Required for Ages < 6 years

CLONIDINE HCL (ADHD) TABLET 12-HOUR KAPVAY Brand Only Preferred Drug PA Required for Ages < 6 years 120.00 30.00

GUANFACINE HCL (ADHD) TABLET 24-HOUR GUANFACINE ER Preferred Drug PA Required for Ages < 6 years 30.00 30.00

CLONIDINE HCL PATCH WEEKLY CATAPRES-TTS PA Required for Ages < 6 years 4.00 28.00

GUANFACINE HCL TABLETS Tenex PA Required for Ages < 6 years

ANALGESICS - OPIOID

OPIOID PARTIAL AGONISTS

BUPRENORPHINE VARIOUS

PA Required unless the member is pregnant-

the prescriber must note the following ICD-

10 codes on the prescription:

1. O09.91- Supervision of high risk

preganancy, 1st Trimester.


preganancy, 2nd Trimester.


preganancy, 3rd Trimester.


preganancy- use for Post-Partum Nursing

Mothers.

AHCCCS Fee-For-Service TRBHA Behavioral Health Drug List

• Generic Preferred Over Brand, Unless Specified as Brand Only AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018

• Drugs Not On The List Are Message Back To The Pharmacy As PA Required

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Preferred Drug

Status PRIOR AUTHORIZATION REQUIRED Quantity Limit QL Days




BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE FILM SUBOXONE FILM Brand Only Preferred Drug

METHADONE VARIOUS

Only avaliable at an Opioid Treatment

Program (OTP) provider.

ANTIANXIETY AGENTS

ANTIANXIETY AGENTS - MISCELLANEOUS.

BUSPIRONE HCL TAB 5 MG BUSPIRONE HCL

PA Required for > 1 Anxiolytic drug in a 30-

day time period. 120.00 30.00

BUSPIRONE HCL TAB 7.5 MG BUSPIRONE HCL












HYDROXYZINE HCL SYRUP ATARAX SYRUP 300.00 30.00

HYDROXYZINE HCL TABLETS ATARAX TABLETS 240.00 30.00

HYDROXYZINE PAMOATE CAPSULES VISTARIL 120.00 30.00

BENZODIAZEPINES

ALPRAZOLAM CONC 1 MG/ML ALPRAZOLAM INTENSOL



ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG VARIOUS



ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG VARIOUS



ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG VARIOUS



ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG VARIOUS



ALPRAZOLAM TAB 0.25 MG VARIOUS



ALPRAZOLAM TAB 0.5 MG VARIOUS



ALPRAZOLAM TAB 1 MG VARIOUS



ALPRAZOLAM TAB 2 MG VARIOUS



ALPRAZOLAM TAB SR 24HR 0.5 MG VARIOUS



ALPRAZOLAM TAB SR 24HR 1 MG VARIOUS









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Preferred Drug





CHLORDIAZEPOXIDE HCL CAP 10 MG VARIOUS









CLONAZEPAM 0.5 MG VARIOUS


day time period.120.00 30.00

CLONAZEPAM 1.0 MGVARIOUS



CLONAZEPAM 2 MGVARIOUS



CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG VARIOUS









CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG VARIOUS






CLORAZEPATE DIPOTASSIUM TAB 15 MG VARIOUS



CLORAZEPATE DIPOTASSIUM TAB 3.75 MG VARIOUS



CLORAZEPATE DIPOTASSIUM TAB 7.5 MG VARIOUS



DIAZEPAM CONC 5 MG/ML DIAZEPAM INTENSOL



DIAZEPAM SOLN 1 MG/ML VARIOUS



DIAZEPAM TAB 10 MG VARIOUS









LORAZEPAM CONC 2 MG/ML LORAZEPAM INTENSOL



LORAZEPAM TAB 0.5 MG VARIOUS



LORAZEPAM TAB 1 MG VARIOUS



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Preferred Drug





LORAZEPAM TAB 2 MG VARIOUS



OXAZEPAM CAP 10 MG VARIOUS









ANTICONVULSANTS

ANTICONVULSANTS - BENZODIAZEPINES

CLONAZEPAM TAB 0.5 MG KLONOPIN

PA Required for > 1 Anxiolytic Medication

in a 30-day time period. 120.00 30.00

CLONAZEPAM TAB 1 MG KLONOPIN



CLONAZEPAM TAB 2 MG KLONOPIN


















ANTICONVULSANTS - MISCELLANEOUS.

CARBAMAZEPINE CHEWABLE TABLETS CARBAMAZEPINE

CARBAMAZEPINE CAPSULE 12-HOUR CARBATROL

CARBAMAZEPINE SUSPENSION TEGRETOL

CARBAMAZEPINE TABLETS EPITOL

CARBAMAZEPINE (ANTIPSYCHOTIC) CAPSULE 12-HOUR EQUETRO

CARBAMAZEPINE TABLET 12-HOUR TEGRETOL-XR

GABAPENTIN CAPSULES NEURONTIN

GABAPENTIN SOLUTION NEURONTIN

GABAPENTIN TABLETS NEURONTIN

LAMOTRIGINE CHEWABLE TABLETS LAMICTAL

LAMOTRIGINE TABLETS LAMICTAL

LAMOTRIGINE TABLET 24-HOUR LAMICTAL XR

OXCARBAZEPINE SUSPENSION TRILEPTAL

OXCARBAZEPINE TABLETS TRILEPTAL

TOPIRAMATE TABLETS TOPAMAX

DIVALPROEX SODIUM CAPSULE SPRINKLE DEPAKOTE SPRINKLES

DIVALPROEX SODIUM TABLET 24-HOUR DEPAKOTE ER

DIVALPROEX SODIUM TABLET ENTERIC COATED DEPAKOTE

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Preferred Drug





VALPROATE SODIUM SYRUP DEPAKENE

VALPROIC ACID CAPSULES DEPAKENE

ANTIDEPRESSANTS

ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

MIRTAZAPINE TABLETS REMERON PA Required for ages < 6 years 30.00 30.00

MIRTAZAPINE TABLET DISPERSIBLE REMERON SOLTAB PA Required for ages < 6 years 30.00 30.00

MONOAMINE OXIDASE INHIBITORS (MAOIS)

ISOCARBOXAZID TABLETS MARPLAN PA Required for ages < 6 years

PHENELZINE SULFATE TABLETS NARDIL PA Required for ages < 6 years

SELEGILINE PATCH 24-HOUR EMSAM PA Required

TRANYLCYPROMINE SULFATE TABLETS PARNATE PA Required for ages < 6 years

NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS (NDRIS)

BUPROPION HCL TABLETS WELLBUTRIN PA Required for ages < 6 years 120.00 30.00

BUPROPION HCL TABLET 12-HOUR BUDEPROPION SR PA Required for ages < 6 years 60.00 30.00

BUPROPION HCL TABLET 24-HOUR WELLBUTRIN XL PA Required for ages < 6 years 30.00 30.00

MAPROTILINE HCL TABLETS MAPROTILINE HCL PA Required for ages < 6 years

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

CITALOPRAM HYDROBROMIDE SOLUTION CITALOPRAM HYDROBROMIDE PA Required for ages < 6 years 600.00 30.00

CITALOPRAM HYDROBROMIDE TABLETS 10MG CELEXA PA Required for Ages < 6 years 60.00 30.00



ESCITALOPRAM OXALATE SOLUTION LEXAPRO PA Required for ages < 6 years 600.00 30.00

ESCITALOPRAM OXALATE TABLETS 5MG LEXAPRO PA Required for Ages < 6 years 60.00 30.00



FLUOXETINE HCL CAPSULES ONLY 10MG PROZAC PA Required for Ages < 6 years 60.00 30.00



FLUOXETINE HCL SOLUTION FLUOXETINE HCL PA Required for Ages < 6 years 600.00 30.00

FLUOXETINE HCL TABLETS - WEEKLY PROZAC WEEKLY PA Required

FLUVOXAMINE MALEATE CAPSULE 24-HOUR 100MG LUVOX CR PA Required for Ages < 6 years 90.00 30.00

FLUVOXAMINE MALEATE CAPSULE 24-HOUR 150MG LUVOX CR PA Required for Ages < 6 years 60.00 30.00

FLUVOXAMINE MALEATE TABLETS 25MG LUVOX PA Required for Ages < 6 years 60.00 30.00



PAROXETINE HCL SUSPENSION PAXIL PA Required for Ages < 6 years 900.00 30.00

PAROXETINE HCL TABLETS 10MG PAXIL PA Required for Ages < 6 years 30.00 30.00




PAROXETINE HCL TABLET 24-HOUR PAXIL CR PA Required for Ages < 6 years 90.00 30.00

PAROXETINE MESYLATE TABLETS PEXEVA PA Required

SERTRALINE HCL CONCENTRATE ZOLOFT PA Required for Ages < 6 years 300.00 30.00

SERTRALINE HCL TABLETS 25MG ZOLOFT PA Required for Ages < 6 years 90.00 30.00


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Preferred Drug






VILAZODONE HCL TABLETS VIIBRYD PA Required

SEROTONIN MODULATORS

NEFAZODONE 50MG VARIOUS PA Required for Ages < 6 years 60.00 30.00





TRAZODONE HCL TABLETS 50MG TRAZODONE HCL PA Required for Ages < 6 years 90.00 30.00




SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI)

DESVENLAFAXINE SUCCINATE TABLET SR 24HR 25 MG (BASE EQUIV) PRISTIQ PA Required for Ages < 6 years 120.00 30.00



DULOXETINE HCL CAPSULE DELAYED RELEASE 20MG CYMBALTA PA Required for Ages < 6 years 120.00 30.00



VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 37.5MG EFFEXOR XR PA Required for Ages < 6 years 90.00 30.00

VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 75MG EFFEXOR XR PA Required for Ages < 6 years 90.00 30.00

VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 150MG EFFEXOR XR PA Required for Ages < 6 years 30.00 30.00

VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 25MG VENLAFAXINE HCL PA Required for Ages < 6 years 120.00 30.00

VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 37.5MG VENLAFAXINE HCL PA Required for Ages < 6 years 90.00 30.00




TRICYCLIC AGENTS

AMITRIPTYLINE HCL TABLETS AMITRIPTYLINE HCL PA Required for ages < 6 years

AMOXAPINE TABLETS AMOXAPINE PA Required for ages < 6 years

CLOMIPRAMINE HCL CAPSULES ANAFRANIL PA Required for ages < 6 years

DESIPRAMINE HCL TABLETS NORPRAMIN PA Required for ages < 6 years

DOXEPIN HCL CAPSULES DOXEPIN HCL PA Required for ages < 6 years 90.00 30.00

DOXEPIN HCL CONCENTRATE DOXEPIN HCL PA Required for ages < 6 years 180.00 30.00

IMIPRAMINE HCL TABLETS TOFRANIL PA Required for ages < 6 years

IMIPRAMINE PAMOATE CAPSULES TOFRANIL-PM PA Required for ages < 6 years

NORTRIPTYLINE HCL CAPSULES PAMELOR PA Required for ages < 6 years

NORTRIPTYLINE HCL SOLUTION NORTRIPTYLINE HCL PA Required for ages < 6 years

PROTRIPTYLINE HCL TABLETS VIVACTIL PA Required for ages < 6 years

TRIMIPRAMINE MALEATE CAPSULES SURMONTIL PA Required for ages < 6 years

ANTIDOTES

OPIOID ANTAGONISTS

NALOXONE HCL SOLUTION + SYRINGE NALOXONE HCL + SYRINGE Preferred Drug

NALOXONE HCL NASAL SPRAY NARCAN NASAL SPRAY Preferred Drug

NALTREXONE HCL TABLETS NALTREXONE HCL Preferred Drug

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Preferred Drug





NALTREXONE SUSPENSION VIVITROL Preferred Drug

ANTIHISTAMINES

ANTIHISTAMINES - ETHANOLAMINES

DIPHENHYDRAMINE HCL CAPSULES VARIOUS

DIPHENHYDRAMINE HCL CHEWABLE TABLETS VARIOUS

DIPHENHYDRAMINE HCL ELIXIR VARIOUS

DIPHENHYDRAMINE HCL LIQUID VARIOUS

DIPHENHYDRAMINE HCL STRIP - REMOVE VARIOUS

DIPHENHYDRAMINE HCL SUSPENSION VARIOUS

DIPHENHYDRAMINE HCL SYRUP VARIOUS

DIPHENHYDRAMINE HCL TABLETS VARIOUS

DIPHENHYDRAMINE HCL TABLET DISPERSIBLE - REMOVE VARIOUS

ANTIHISTAMINES - PIPERIDINES

CYPROHEPTADINE HCL SYRUP CYPROHEPTADINE HCL

CYPROHEPTADINE HCL TABLETS CYPROHEPTADINE HCL

ANTIHYPERTENSIVES

ANTIADRENERGIC ANTIHYPERTENSIVES

PRAZOSIN HCL CAPSULES MINIPRESS

ANTIPARKINSON AGENTS

ANTIPARKINSON ANTICHOLINERGICS

BENZTROPINE MESYLATE SOLUTION COGENTIN

BENZTROPINE MESYLATE TABLETS BENZTROPINE MESYLATE

TRIHEXYPHENIDYL HCL ELIXIR TRIHEXYPHENIDYL HCL

TRIHEXYPHENIDYL HCL TABLETS TRIHEXYPHENIDYL HCL

ANTIPARKINSON DOPAMINERGICS

AMANTADINE HCL CAPSULES AMANTADINE HCL

AMANTADINE HCL SYRUP AMANTADINE HCL

AMANTADINE HCL TABLETS AMANTADINE HCL

ANTIPSYCHOTICS/ANTIMANIC AGENTS

ANTIMANIC AGENTS

LITHIUM CARBONATE CAPSULES LITHIUM CARBONATE

LITHIUM CARBONATE TABLETS LITHIUM CARBONATE

LITHIUM CARBONATE TABLET CONTROLLED RELEASE LITHOBID

LITHIUM SOLUTION LITHIUM

ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL ORAL AGENTS

ARIPIPRAZOLE TABLETS ABILIFY Preferred Drug PA Required for Ages < 6 years 30.00 30.00

ARIPIPRAZOLE ORALLY DISPERSABLE TABLET ABILIFY Preferred Drug PA Required for Ages < 6 years 30.00 30.00

ARIPIPRAZOLE SOLUTION ABILIFY Preferred Drug PA Required for Ages < 6 years 150.00 30.00

ASENAPINE MALEATE SUBLINGUAL SAPHRIS Brand Only Preferred Drug PA Required for Ages < 6 years 60.00 30.00

CLOZAPINE ORALLY DISPERSABLE TABLET FAZACLO Preferred Drug PA Required for Ages < 18 years 150.00 30.00

CLOZAPINE TABLETS CLOZARIL Preferred Drug PA Required for Ages < 18 years 150.00 30.00

LURASIDONE HCL TABS LATUDA Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00

OLANZAPINE ORALLY DISPERSABLE TABLET 5MG ZYPREXA ZYDIS Preferred Drug PA Required for Ages < 6 years 60.00 30.00



11


Preferred Drug






OLANZAPINE TABLETS ZYPREXA Preferred Drug PA Required for Ages < 6 years 30.00 30.00

QUETIAPINE FUMARATE TABLETS SEROQUEL Preferred Drug PA Required for Ages < 6 years 60.00 30.00

RISPERIDONE ORALLY DISPERSABLE TABLET RISPERIDONE ODT Preferred Drug PA Required for Ages < 6 years 60.00 30.00

RISPERIDONE ORAL SOLUTION RISPERDAL Preferred Drug PA Required for Ages < 6 years 240.00 30.00

RISPERIDONE TABLETS RISPERDAL Preferred Drug PA Required for Ages < 6 years 60.00 30.00

ZIPRASIDONE HCL CAPSULES GEODON Preferred Drug PA Required for Ages < 6 years 60.00 30.00

ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL LONG ACTING INJECTABLES

ARIPIPRAZOLE LAUROXIL ARISTADA Brand Only Preferred Drug PA Required for Ages < 18 years 1.00 30.00

ARIPIPRAZOLE SUSPENSION ABILIFY MAINTENA Brand Only Preferred Drug PA Required for Ages < 18 years 1.00 30.00

PALIPERIDONE PALMITATE SUSPENSION INVEGA SUSTENNA Brand Only Preferred Drug PA Required for Ages < 18 years 1.00 30.00

PALIPERIDONE PALMITATE SUSPENSION INVEGA TRINZA Brand Only Preferred Drug PA Required for Ages < 18 years 1.00 90.00

RISPERIDONE MICROSPHERES SUSPENSION RISPERDAL CONSTA Brand Only Preferred Drug PA Required for Ages < 18 years 2.00 30.00

ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL ORAL AGENTS

CHLORPROMAZINE HCL SOLUTION VARIOUS PA Required for Ages < 6 years

CHLORPROMAZINE HCL TABLETS VARIOUS PA Required for Ages < 6 years

FLUPHENAZINE HCL CONCENTRATE VARIOUS PA Required for Ages < 6 years

FLUPHENAZINE HCL ELIXIR VARIOUS PA Required for Ages < 6 years

FLUPHENAZINE HCL TABLETS VARIOUS PA Required for Ages < 6 years

HALOPERIDOL LACTATE CONCENTRATE VARIOUS PA Required for Ages < 6 years

HALOPERIDOL TABLETS VARIOUS PA Required for Ages < 6 years

LOXAPINE SUCCINATE CAPSULES LOXITANE PA Required for Ages < 6 years

PERPHENAZINE TABLETS VARIOUS PA Required for Ages < 6 years

PIMOZIDE ORAP PA Required for Ages < 6 years

THIORIDAZINE HCL TABLETS VARIOUS PA Required for Ages < 6 years

THIOTHIXENE CAPSULES VARIOUS PA Required for Ages < 6 years

TRIFLUOPERAZINE HCL TABLETS VARIOUS PA Required for Ages < 6 years

ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL -LONG ACTING INJECTIONS

FLUPHENAZINE DECANOATE SOLUTION FLUPHENAZINE DECANOATE PA Required for Ages < 18 years

HALOPERIDOL DECANOATE SOLUTION HALDOL DECANOATE PA Required for Ages < 18 years

BETA BLOCKERS

BETA BLOCKERS NON-SELECTIVE

NADOLOL TABLETS CORGARD

PROPRANOLOL HCL CAPSULE 24-HOUR INDERAL LA 30.00 30.00

PROPRANOLOL HCL SOLUTION PROPRANOLOL HCL

PROPRANOLOL HCL SUSTAINED-RELEASE BEADS CAPSULE 24-HOUR INDERAL XL 30.00 30.00

PROPRANOLOL HCL TABLETS PROPRANOLOL HCL

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENT

ANTIHISTAMINE HYPNOTICS

DIPHENHYDRAMINE HCL (SLEEP) CAPSULES VARIOUS

DIPHENHYDRAMINE HCL (SLEEP) LIQUID VARIOUS

DIPHENHYDRAMINE HCL (SLEEP) TABLETS VARIOUS

DIPHENHYDRAMINE HCL (SLEEP) TABLET DISPERSIBLE VARIOUS

HYPNOTICS - TRICYCLIC AGENTS

DOXEPIN HCL (SLEEP) TABLETS SILENOR PA Required

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Preferred Drug





NON-BARBITURATE HYPNOTICS

TEMAZEPAM CAPSULES 15MG & 30MG RESTORIL PA Required for > 1 Hypnotic 30.00 30.00

ZOLPIDEM TARTRATE TABLETS 5MG AMBIEN PA Required for > 1 Hypnotic 60.00 30.00

ZOLPIDEM TARTRATE TABLETS 10MG AMBIEN PA Required for > 1 Hypnotic 30.00 30.00

SELECTIVE MELATONIN RECEPTOR AGONISTS

RAMELTEON TABLETS ROZEREM

Patient must have tried Temazepam and

Zolpidem

LAXATIVES

BULK LAXATIVES

FIBER CAPSULES

ADVANCED FIBER

COMPLEX/ACIDOPHILUS

FIBER CHEWABLE TABLETS FIBER SELECT GUMMIES

FIBER LIQUID LIQUAFIBER

FIBER POWDER FIBER

FIBER TABLETS FIBER COMPLETE

METHYLCELLULOSE (LAXATIVE) PACK CITRUCEL FIBER LAXATIVE

METHYLCELLULOSE (LAXATIVE) POWDER CITRUCEL FIBER LAXATIVE

METHYLCELLULOSE (LAXATIVE) TABLETS CITRUCEL

PSYLLIUM CAPSULES NAT-RUL PSYLLIUM SEED HUSKS

PSYLLIUM PACK METAMUCIL SMOOTH TEXTURE

PSYLLIUM POWDER KONSYL

PSYLLIUM WAFER METAMUCIL

LAXATIVES - MISCELLANEOUSELLANEOUS

LACTULOSE PACK KRISTALOSE

LACTULOSE SOLUTION LACTULOSE

SALINE LAXATIVES

MAGNESIUM CITRATE SOLUTION CITROMA

MAGNESIUM OXIDE (LAXATIVE) TABLETS PHILLIPS

STIMULANT LAXATIVES

BISACODYL ENEMA FLEET BISACODYL

BISACODYL KIT DULCOLAX BOWEL PREP KIT

BISACODYL SUPPOSITORY BISAC-EVAC

BISACODYL TABLET ENTERIC COATED ALOPHEN

CASCARA SAGRADA CAPSULES CASCARA SAGRADA

CASCARA SAGRADA EXTR CASCARA SAGRADA

CASCARA SAGRADA TABLETS CASCARA SAGRADA

SENNA LEAV SENNA LEAVES

SENNA MISCELLANEOUS CORRECTOL HERBAL TEA

SENNA SYRUP SENNA

SENNA TABLETS NATURAL SENNA LAXATIVE

SENNOSIDES CAPSULES SENNA

SENNOSIDES CHEWABLE TABLETS BLACK DRAUGHT

SENNOSIDES LIQUID AGORAL MAXIMUM STRENGTH

SENNOSIDES TABLETS DR EDWARDS OLIVE LAXATIVE

SURFACTANT LAXATIVES

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Preferred Drug





DOCUSATE SODIUM CAPSULES COLACE

DOCUSATE SODIUM ENEMA DOCUSOL KIDS

DOCUSATE SODIUM LIQUID PEDIA-LAX

DOCUSATE SODIUM SYRUP DIOCTO

MOUTH/THROAT/DENTAL AGENTS

THROAT PRODUCTS - MISCELLANEOUS.

ARTIFICIAL SALIVA AEROSOL SOLUTION AQUORAL

ARTIFICIAL SALIVA GEL

BIOTENE ORALBALANCE DRY MOUTH

MOISTURIZING

ARTIFICIAL SALIVA GUM BIOTENE DRY MOUTH GUM

ARTIFICIAL SALIVA KIT

ORAL RELIEF FOR DRY MOUTH&

DISCOMFORT

ARTIFICIAL SALIVA LOZENGE ACT DRY MOUTH

ARTIFICIAL SALIVA PACK NEUTRASAL

ARTIFICIAL SALIVA SOLUTION BIOTENE MOISTURIZING MOUTH SPRAY

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENT

AGENTS FOR CHEMICAL DEPENDENCY

ACAMPROSATE CALCIUM TABLET ENTERIC COATED VARIOUS

DISULFIRAM TABLETS VARIOUS

POSTHERPETIC NEURALGIA (PHN) AGENTS

GABAPENTIN (ONCE-DAILY) TABLETS GRALISE PA Required

RESTLESS LEG SYNDROME (RLS) AGENTS

GABAPENTIN ENACARBIL TABLETS ER HORIZANT PA Required

PIMOZIDE TABLETS ORAP

THYROID AGENTS

THYROID HORMONES

LEVOTHYROXINE SODIUM TABLETS LEVO-T 30.00 30.00

LIOTHYRONINE SODIUM TABLETS CYTOMEL 30.00 30.00

VITAMINS

OIL SOLUBLE VITAMINS

VITAMIN E CAPSULES VITAMIN E

VITAMIN E CHEWABLE TABLETS KEY-E

VITAMIN E LIQUID LIQUI-E

VITAMIN E TABLETS VITAMIN E

WATER SOLUBLE VITAMINS

NIACIN CAPSULE CONTROLLED RELEASE NIACIN

NIACIN TABLETS NIACIN

NIACIN TABLET CONTROLLED RELEASE ENDUR-ACIN

NIACINAMIDE TABLETS NIACINAMIDE

NIACINAMIDE TABLET CONTROLLED RELEASE NIACINAMIDE PROLONGED RELEASE

PYRIDOXINE HCL CAPSULES NEURO-K-250 T.D.

PYRIDOXINE HCL LOZENGE B-NATAL

PYRIDOXINE HCL LOLLIPOP B-NATAL

PYRIDOXINE HCL SOLUTION PYRIDOXINE HCL

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Preferred Drug





PYRIDOXINE HCL TABLETS PYRIDOXINE HCL

PYRIDOXINE HCL TABLET CONTROLLED RELEASE VITAMIN B-6

RIBOFLAVIN CAPSULES RIBOFLAVIN

RIBOFLAVIN TABLETS VITAMIN B-2

THIAMINE HCL CAPSULES THIAMINE

THIAMINE HCL SOLUTION THIAMINE HCL

THIAMINE HCL TABLETS VITAMIN B-1

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AHCCCS Fee-For-Service Program T(RBHA) Drug List (BHDL ... · 2 Optum Rx Prior Authorization...

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